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International Scholarly Research NetworkISRN Emergency MedicineVolume 2012, Article ID 259864, 6 pagesdoi:10.5402/2012/259864

Research Article

Teaching Emergency Surgical Skills forTrauma Resuscitation-Mechanical Simulator versusAnimal Model

Jameel Ali, Anne Sorvari, and Anand Pandya

Department of Surgery, St. Michael’s Hospital, University of Toronto, 55 Queen Street East,Suite No. 402, Toronto, ON, Canada M5C 1R6

Correspondence should be addressed to Jameel Ali, [email protected]

Received 8 August 2012; Accepted 27 August 2012

Academic Editors: A. K. Attri, D. Doll, A. Eisenman, and M. Mohsin

Copyright © 2012 Jameel Ali et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Traditionally, surgical skills in trauma resuscitation have been taught using animal models in the advanced trauma lifesupport (ATLS) course. We compare one mechanical model (TraumaMan simulator) as an alternative teaching tool for these skills.Method. Eighteen providers and 14 instructors performed four surgical procedures on TraumaMan and compared educationaleffectiveness with the porcine model. Evaluation was conducted (Likert system 1: very poor to 5: excellent). The participantsindicated if TraumaMan was a suitable (scale 1: not suitable to 4: excellent) ATLS teaching model considering cost, animal ethicsconcerns, and other factors. Comments were solicited for both models. Results. Overall ratings for educational effectiveness of the4 skills ranged from 3.58 to 4.36 for the porcine and 3.48 to 4.29 for the TraumaMan model. TraumaMan suitability was rated 3-4(mean 3.38) by 84% participants. TraumaMan as a substitute for the porcine model was recommended by 85% participants. Withno ethical or cost concerns, 44% students and 71% instructors preferred TraumaMan. Considering all factors, TraumaMan waspreferred by 78% students and 93% instructors. Conclusions. TraumaMan is a suitable alternative to the porcine model andconsidering all factors it may be the preferred method for teaching ATLS emergency trauma surgical skills.

1. Introduction

Resuscitation of critically injured patients is conductedprimarily in the emergency room setting. The surgical resus-citation skills have been taught internationally through theAdvanced Trauma Life Support (ATLS) Course of the Ameri-can college of Surgeons. This course was introduced inNebraska in the 1970s [1] and adopted by American Collegeof Surgeons (ACS) in an effort to standardize and improvemanagement of trauma patients. Since then, more than amillion doctors in 62 countries have completed this course,which consists of lectures, group discussions, standardizedpatients, and technical skill stations. An important com-ponent of the ATLS program is the surgical skills stationwhich provides hands-on training in performing proceduressuch as cricothyroidotomy, chest tube insertion, pericardio-centesis, and diagnostic peritoneal lavage (DPL). Logistic,

societal, and economic issues have prompted the develop-ment of alternatives to the animal model including humanpatient simulators (HPS) in teaching the surgical skillscomponent.

The use of simulation-based technology in traumaeducation has provided a means for enhancing patientsafety, reducing medical errors, and performing systematicevaluation of various competencies [2–4]. The AmericanCollege of Surgeons has approved the TraumaMan (SimulabCorporation, Seattle, WA, USA) along with other models asalternatives for teaching ATLS surgical skills after evaluationby members of the ATLS subcommittee. The TraumaMansystem consists of a mechanical model with simulatedhuman tissue structure designed specifically to mimic thesurgical dissection of the thoracic, abdominal, and neckregions for teaching the ATLS surgical skills. Due to ethicalconcerns surrounding the use of animals for teaching and

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2 ISRN Emergency Medicine

(1) For the surgical procedures please rate the educational effectiveness of the model inlearning the skill using the following Likert Scale (1 = very poor, 2 = poor,3 = satisfactory, 4 = very good, 5 = excellent)(2) Recognizing the concerns for using animal models for learning surgical skills and theneed to find a nonanimal model, please rate the degree to which you think theTraumaMan is a suitable model for learning surgical skills in the ATLS course.Please use the following Likert scale (1 = not suitable, 2 = acceptable, 3 = veryacceptable, 4 = excellent)(3) Would you recommend the TraumaMan as a substitute for the animal model? (Yes,Neutral, No)(4) Overall, if there were no ethical or animal model concerns, which model will yourecommend?(5) Overall, considering all factors (animal concerns, suitability of the models, financial,etc.) which model would you recommend?

Box 1: Survey to compare the effectiveness of the porcine model versus TraumaMan for teaching ATLS surgical skills.

the availability of accredited alternatives, more than two hun-dred ATLS course centers in the United States have adoptedhuman patient simulators for teaching surgical skills. How-ever, this alternative has not been uniformly accepted [5].Many, including those who feel compelled to use mechanicalmodels because of animal ethics concerns, have questionedtheir suitability for teaching the resuscitation surgical skills.An unbiased comparison of the mechanical and animalmodels seems warranted. Our experience with the porcinemodel has been excellent. However, animal ethics approvalfor the use of animal teaching models requires assurance thatno alternative nonanimal model is suitable for this purpose.We therefore embarked on a study to determine the suitabil-ity of one of the available mechanical models for surgicalskills teaching in the ATLS course—TraumaMan.

2. Materials and Methods

ATLS surgeon instructors and surgical residents who hadpreviously taught or completed our ATLS courses using theporcine model were openly invited to assess the Trauma-Man simulator. After a brief orientation, all participantsperformed the necessary surgical skills of cricothyroido-tomy, chest tube insertion, pericardiocentesis, and diagnosticperitoneal lavage. Following the practicum, participantscompleted a feedback questionnaire covering 5 componentsas indicated in Box 1. A Likert scale of 1: very poor to 5:excellent was used for educational effectiveness. Suitabilitywas rated on a 4-point Likert scale of 1: not suitable to 4:excellent. Items 3–5 in Box 1 were completed as indicated.Participants were also invited to make general comments onthe advantages and disadvantages of both models and thesewere reviewed.

The mean and standard deviations of the Likert scoreswere calculated and between-group comparisons conductedusing unpaired t-tests. Model preferences were comparedby Fischer Exact test. A P value of ≤0.05 was regarded asstatistically significant.

3. Results

Thirty-two participants (18 students, 14 ATLS instructors)evaluated ATLS surgical skills on the TraumaMan modeland compared this to previous experience using the animalmodel. Please note that in the tables the numbers do notalways add up to 32 because of variation in the number ofresponses received for these items.

Table 1 shows the survey results for all participants onthe educational effectiveness of the porcine and TraumaManmodels with the mean ratings out of a maximum of 5. Forchest tube insertion, 28 participants in the porcine modeland 26 in the TraumaMan model rated 4 or 5. Correspondingcricothyroidotomy ratings of 4 to 5 were from 27 participantsfor TraumaMan and 16 for the porcine model. Correspond-ing ratings of 4-5 for DPL came from 25 participants for theporcine model and 15 in TraumaMan. For pericardiocentesisa rating of 4-5 was assigned by 20 participants in the porcinemodel and 26 in the TraumaMan model. Mean (SD±)Likert scores for each procedure are also shown in Table 1.Also shown are the P values for comparing each of thoseprocedures between TraumaMan and the porcine model,where it is seen that TraumaMan had higher scores in twoprocedures (pericardiocentesis, P = 0.0195, and cricothy-roidotomy, P = 0.0010), porcine model higher in oneprocedure (DPL, P = 0.0089), and no statistically significantdifference with the chest tube (P = 0.3759).

Table 2 shows that, considering animal ethical concerns,overall 84% of participants considered TraumaMan to bevery acceptable to excellent as a teaching model for the ATLSsurgical skills with an overall mean rating of 3.38 out of 4.Also, Table 2 shows the P value of 0.079 for the comparisonbetween TraumaMan and the porcine model.

As indicated in Table 3, TraumaMan was recommendedas a substitute for the porcine model by 85% of participantsand there was no statistically significant difference betweenthe recommendations between students and teachers (P =0.3547, by Fisher Exact Test). Comparing yes to no/neutralresulted in a P value of 0.0043 for recommending Trauma-man as indicated in Table 3.

ISRN Emergency Medicine 3

Table 1: Survey scores of the porcine versus TraumaMan for educational effectiveness of the surgical skills.

Very Poor Poor Satisfactory Very good Excellent

1 2 3 4 5

ATLS surgical skills: porcine model scores

Chest tube 0 0 13% (4) 41% (13) 47% (15)

Pericardiocentesis 0 7% (2) 27% (8) 53% (16) 13% (4)

DPL 0 0 19% (6) 58% (18) 23% (7)

Cricothyroidotomy 0 6% (2) 44% (14) 34% (11) 16% (5)

ATLS surgical skills: TraumaMan scores

Chest tube 0 3% (1) 16% (5) 41% (13) 41% (13)

Pericardiocentesis 0 0 19% (6) 66% (21) 16% (5)

DPL 0 0 52% (16) 39% (12) 10% (3)

Cricothyroidotomy 0 3% (1) 13% (4) 38% (12) 47% (15)

Porcine TraumaMan P value

Chest tube 4.36 (SD ± 0.70) 4.19 (SD ± 0.82) P = 0.3759

Cricothyroidotomy 3.58 (SD ± 0.84) 4.29 (SD ± 0.81) P = 0.0010

DPL 3.94 (SD ± 0.67) 3.48 (SD ± 0.67) P = 0.0089

Pericardiocentesis 3.55 (SD ± 0.78) 3.97 (SD ± 0.59) P = 0.0195

Table 2: Suitability for learning surgical skills in the ATLS course with TraumaMan recognizing the concerns of animal models.

ParticipantsScores

Mean score1 2 3 4

Student (n = 18) 0 4 7 7 3.17 (SD ± 0.79)P value = 0.079

Teacher (n = 14) 0 1 3 10 3.64 (SD ± 0.63)

Overall (n = 32) 0 5 (16%) 10 (31%) 17 (53%) 3.38 (SD ± 0.75)

1: Not suitable, 2: acceptable, 3: very acceptable, and 4: excellent.

Table 3: Recommend TraumaMan as a substitute for the porcinemodel.

−1 0 1

No Neutral Yes

Student (n = 18) 2 2 14

Teacher (n = 14) 0 1 13

Overall (n = 32) 2 (6%) 3 (9%) 27 (85%)

Fisher Exact Test comparing No/Neutral to Yes, P = 0.0043.

Table 4 shows that if there were no ethical or animalmodel concerns, then overall 56% of participants wouldrecommend the use of TraumaMan versus 44% who wouldprefer the use of the porcine model for ATLS training.However, 71% of instructors versus 44% of students preferTraumaMan. P value by Fisher Exact Test between studentsand instructors was 0.0002.

Table 5 demonstrates that participants overwhelmingly(93% instructors and 78% students) support the use of Trau-maMan for training in ATLS surgical skills while consideringall factors (ethical, financial, portability and suitability forlearning), (P = 0.0043 by Fisher Exact Test). However, therewas a clear difference in preference for TraumaMan betweeninstructors (71% with no concerns and 93% consideringall factors) and students (44% with no concerns and 78%considering all factors).

From the feedback provided in the comments (detailedin Table 6), participants preferred the animal model dueto more realistic surgical handling, dynamic tissue changes,and good anatomical detail. The disadvantage of the animalmodel included the ethical dilemma related to sacrifice ofthe animal, the inability to repeatedly practice on the sameanimal, and the requirement for an animal care facility.Furthermore the airway anatomy in the porcine model wasnot similar to humans and the cricothyroidotomy procedurecould only be performed once on the animal model.

In contrast, the advantages of TraumaMan included theabsence of ethical concerns, ability to repeat procedures con-sistently on the model, the portability and availability of themodel without the need for special vivarium facilities, andthe opportunity for all participants to practice all the surgicalskills especially cricothyroidotomy. The disadvantages of theTraumaMan model included the initial capital cost and thebrittle rubbery feel of the tissues especially while insertingthe chest tube. However, many participants indicated that theunrealistic feel was less important to teaching compared tothe ethical dilemma of animal use.

4. Discussion

The use of simulation to educate and train physicians hasbeen gaining increasing attention since the Institute ofMedicine issued its 1999 report, “To Err is Human” [6].


Table 4: Preference for training in ATLS surgical skills if there were no ethical or porcine model considerations.

Participants Porcine model (%, n) TraumaMan preference (%, n) Fisher Exact Test comparing students with teachers

Student (n = 18) 56% (10) 44% (8)P = 0.0002

Teacher (n = 14) 29% (4) 71% (10)

Overall (n = 32) 44% (14) 56% (18)

Table 5: Preference for training in ATLS surgical skills considering all factors.

Participants Porcine Model (%, n) TraumaMan preference (%, n)

Student (n = 18) 22% (4) 78% (14)

Teacher (n = 14) 7% (1) 93% (13)

Overall (n = 32) 16% (5) 84% (27)

P = 0.0043 by Fisher Exact Test comparing TraumaMan to the porcine model.

The Institute of Medicine report suggested that innovativeapproaches to education and the use of simulation technol-ogy may help to reduce the projected 98,000 deaths thatoccur each year in the United States because of medicalerrors. As a result, simulation technology has now beenembraced by a variety of specialties as an advanced edu-cational tool for training and evaluation of clinical per-formance [7, 8]. In order for simulators to be effective,it is important to overcome three potential challenges: (1)realism: organ responses, physiologic variables, tissue-toolinterfaces, visual displays, and real-time interactions shouldbe as realistic to the user as possible; (2) authenticity: sim-ulation technology should be easily integrated into educa-tional curricula, provide training that is clinically useful, andallow for validated performance metrics; (3) acceptability:commitment to simulated testing in medical centers, accep-tance by teaching faculty, and approval and support by med-ical specialty organizations such as the American Associationfor surgery of Trauma. In addition, provision of devices at anacceptable financial cost is also needed [9].

The use of simulation based technology in trauma edu-cation has focused on providing a safe and effective alterna-tive to the more traditional methods that are used to teachtechnical skills and critical concepts in trauma resuscitation[10]. In recent years, TraumaMan has become widely usedin ATLS as an adjunct to teach essential surgical skills. Theutility of TraumaMan for ATLS education was investigatedby Block et al. [11] in 2002. In their study, students foundTraumaMan to be superior to traditional animal models forlearning surgical airway skills and the management of pneu-mothorax. Berkenstadt et al. [12] in 2006 further evaluatedTraumaMan as a training tool for chest drain insertion.According to the participants, the TraumaMan simulator wassuperior to the animal model only in teaching anatomicallandmarks, while the animal model was superior in teachingtissue handling, dissection, and chest drain fixation. Thepresent study differs from those previously reported in thatwe compared the training effectiveness and preferences ofstudents and instructors for all four ATLS surgical skills inboth the porcine and TraumaMan models in ATLS teaching.Considering the ethical issues related to animal use, Trauma-Man was the overwhelmingly preferred model.

To meet the increasing demand for trauma-based edu-cation using simulation, a number of commercial simulatorshave been introduced to meet specific educational objectives.Airway management using the Air-Man simulator (Laerdal,Norway), High Fidelity Patient Simulator (METI), and theSimMan simulator have been used to teach airway manage-ment skills in trauma patients. The VIRGIL Chest TraumaTraining System (the Simulation Group-CIMIT, Boston,MA) is used for the training of medics in combat casualty[13]. There is an ongoing need to selectively develop addi-tional high-fidelity simulators and software for computerizedinstruction and innovative web-based teaching. As thesetechnologies are developed, there must be a concerted effortto formally validate and demonstrate that these modalitiesare as good as, if not better than, traditional methodsof trauma teaching. Convincing evidence is necessary iftrauma-based simulation is to become a strong, viable, anduniversally accepted teaching adjunct.

A very important consideration in utilizing the animalmodel for ATLS training is the ethical dilemma of animaluse when an alternative method is available. Surgeons havelong practiced and learned their skills on live pigs becauseof their anatomical similarities to humans. In 2006, statisticsfrom the Canadian Council on Animal Care show that 38,000pigs were used for education [5]. The American College ofSurgeons, which accredits the ATLS program, has approvedthe use of human patient simulators such as TraumaMan toteach the 4 procedures—chest tube insertion, pericardio-centesis, peritoneal lavage, and cricothyroidotomy. Thisapproval, however, was not accompanied by formal compar-ison of these mechanical models with the animal model as isreported in our study. With the acceptance of the mechanicalmodel as a suitable alternative for teaching the ATLS surgicalskills, many animal ethics committees may not approvelive animal use for teaching these skills. In addition, thepreparation time and provision of live animal models addsignificant time commitment as well as cost to support ananimal care facility. However, the feasibility of utilizing theTraumaMan model is limited by the number of models andthe high cost for providing these models for student training($25,000 USD per model). Once acquired, these mechanicalmodels provide a continuing medium for clinical education[14].

ISRN Emergency Medicine 5

Table 6: Summary of comments by participants.

Advantages Disadvantages

Porcine model

(i) More realistic feel and handling (i) Ethical concerns—having to sacrifice the animal

(ii) More surgically realistic (ii) Cannot repeatedly practice on the same animal

(iii) Real-time live animal (iii) Cricothyroidotomy can only be done once

(iv) Moving tissues (iv) Expensive

(v) Anatomic detail is good—representation of the layers of body wall (v) Airway anatomy is not similar to human

(vi) Likely cheaper

(vii) Presence of blood in operative procedure field

(viii) Presence of active monitoring more like trauma bay

(ix) Psychological factor of practicing on a living animal

TraumaMan model

(i) Ethical advantage—no animal use (i) Not real feel of human tissue

(ii) Procedures can be repeated many times (ii) Not real feel to chest wall

(iii) Cost advantage versus animal (iii) Cost of trauma man

(iv) Consistent anatomy (iv) Bloodless field

(v) Easy to learn and practice (v) Cricothyroidotomy space is larger than reality

(vi) Easy to teach (vi) Tissues more brittle than human—chest wall is easy to enter

(vii) Always available for practice (vii) Rubber poorly simulates skin

(viii) Good to learn landmarks—similar to human anatomy (viii) Needs better simulation of underlying tissue layers

(ix) Less smelly

(x) Reproducible technique

(xi) Opportunity for all participants to try all procedures

(xii) Portability—can be transported to another hospital

(xiii) No need for special animal laboratory space

(xiv) Reusable

Additional Comments(i) Combined tissue/synthetic model may be more preferable.(ii) Cricothyroidotomy needs a more elaborate anatomical kit with more details.(iii) Chest wall is easy to enter. It may benefit from more thickness or layers in the TraumaMan model.(iv) Unrealistic feel is less important to teaching compared to ethical dilemmas with animal use.

There are several limitations of this study. The size of thepopulation studied was quite small. Conceivably increasingthe statistical power and widening the Likert response scalemay yield different results. One of the possible biases in thisstudy may lay in participants’ attitude towards the use of ani-mals for training, which could change their attitude in favorof one of the training modalities. The participation in thisstudy was voluntary and it is conceivable that only subjectsinterested in the respective models may have participatedleading to possible bias.

In spite of these limitations, our study appears to havedemonstrated the effectiveness of the TraumaMan simulatorin teaching the surgical skills of the ATLS course. TheTraumaMan model is perceived as providing better trainingwith respect to surgical airway skills and pericardiocentesis.The TraumaMan model is also considered to be the preferredtraining tool given the ethical, financial, and resourceconstraints related to animal use.

As a result of our study, we have switched our surgicalskills model in the ATLS course to TraumaMan because wecould not justify identifying animals as the only suitablesource for providing the necessary training in our ethics

application for renewal. Conceivably other mechanical mod-els may prove just as educationally effective but our study waslimited to comparing TraumaMan with the porcine modeland thus we are unable to comment on the other modelswhich could also be suitable substitutes for the porcinemodel.

References

[1] P. E. Collicott and I. Hughes, “Training in advanced traumalife support,” The Journal of the American Medical Association,vol. 243, no. 11, pp. 1156–1159, 1980.

[2] R. K. Reznick and H. MacRae, “Teaching surgical skills—changes in the wind,” The New England Journal of Medicine,vol. 355, no. 25, pp. 2664–2669, 2006.

[3] J. Ali, R. U. Adam, I. Sammy, E. Ali, and J. I. Williams, “Thesimulated trauma patient teaching module—does it improvestudent performance?” Journal of Trauma—Injury, Infectionand Critical Care, vol. 62, no. 6, pp. 1416–1420, 2007.

[4] M. M. Knudson and A. C. Sisley, “Training residents usingsimulation technology: experience with ultrasound for trau-ma,” Journal of Trauma—Injury, Infection and Critical Care,vol. 48, no. 4, pp. 659–665, 2000.


[5] R. Collier, “Switching swine for simulators: at what cost?”Canadian Medical Association Journal, vol. 179, no. 8, pp. 759–760, 2008.

[6] L. T. Kohn and J. M. Corrigan, Donaldson m Sets, “To ErrIs HuMan”, Institute of Medicine, National Academy Press,Washington, DC, USA, 1999.

[7] J. Ali, T. J. Gana, and M. Howard, “Trauma mannequin assess-ment of management skills of surgical residents after advancedtrauma life support training,” Journal of Surgical Research, vol.93, no. 1, pp. 197–200, 2000.

[8] J. Ali, R. J. Cohen, T. J. Gana, and K. F. Al-Bedah, “Effect of theadvanced trauma life support program on medical student’sperformance in simulated trauma patient management,” Jour-nal of Trauma—Injury, Infection and Critical Care, vol. 44, no.4, pp. 588–591, 1998.

[9] S. L. Dawson, “A critical approach to medical simulation.,”Bulletin of the American College of Surgeons, vol. 87, no. 11,pp. 12–18, 2002.

[10] R. A. Cherry and J. Ali, “Current concepts in simulation-basedtrauma education,” The Journal of Trauma, vol. 65, no. 5, pp.1186–1193, 2008.

[11] E. F. J. Block, L. Lottenberg, L. Flint, J. Jakobsen, andD. Liebnitzky, “Use of a human patient simulator for theadvanced trauma life support course,” The American Surgeon,vol. 68, no. 7, pp. 648–651, 2002.

[12] H. Berkenstadt, Y. Munz, G. Trodler, A. Blumenfeld, O. Rubin,and A. Ziv, “Evaluation of the Trauma-man simulator fortraining in chest drain insertion,” European Journal of Trauma,vol. 32, no. 6, pp. 523–526, 2006.

[13] Virgil, Device developed in simulation program, lauded byarmy general, http://www.cimit.org/news/virgil.html.

[14] J. Ali, K. A. Ahmadi, J. I. Williams, and R. A. Cherry, “Thestandardized live patient and mechanical patient models theirroles in trauma teaching,” Journal of Trauma—Injury, Infectionand Critical Care, vol. 66, no. 1, pp. 98–102, 2009.

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